Managing Follicular Lymphoma: State of the Art

From the most recent issue of the journal Leukemia: "How We Manage Follicular Lymphoma."

Yes, Leukemia also publishes research on "allied diseases," like lymphoma. They are also awesome, allowing their articles to be viewed online, which is why we get to read this one.

The "we" in the title is Dr. Wolfgang Hiddemann from the university of Munich, and our own Lymphoma Rock Star Dr. Bruce Cheson.

Nothing really new here, which is fine: Hiddemann and Cheson are describing what they typically do for patients at different stages of Follicular Lymphoma. So while it isn't a report on new research, it is a report on what works now and what two specialists think might work in the near future. So this is about as "state of the art" a discussion of Follicular Lymphoma as you are likely to find anywhere for today.

It's also pretty accessible, so you don't need a lot of commentary from me. But I'll give you a summary, anyway.

The good doctors look first at Stage 1 and 2 Follicular Lymphoma, and point out that while radiation therapy is often adequate for these patients, it is used less than one-third of the time. They also make a push for better care in staging, which has an impact on patients in this group.

In looking at "advanced stage" (3 and 4, which is where most of us fall), they divide us into two groups: those with low tumor burden and without symptoms, and those with high tumor burden and some symptoms. These two types obviously present different problems to be solved.

First, for low burden/no symptoms, they confirm that watching and waiting is still a valid approach. They also discuss straight Rituxan as an initial treatment, as well as Rituxan Maintenance. And then they compare the two approaches, something Cheson has done several times before. And as he has done before, Cheson still comes out in favor of watching and waiting, on the basis that there is still no evidence that immediate treatment gives any better results.

For those with symptoms and/or bulky disease, they review the options available: R plus chemo (CHOP and Bendamustine continue to be the chemos of choice). And after remission, there are further options: RadioImmunoTherapy, Auto Stem Cell Transplants, R-Maintenance, and all of the controversies that go along with those options.

Next, the doctors review "New Agents," and their excitement is evident. They discuss new CD20 antibodies (possible replacements for Rituxan, such as Obinutuzumab/GA 101); antibodies that target proteins other than CD20, such as Epratuzumab and Galiximab; and some treatments that target pathways, including the various kinase inhibitors that are getting people excited lately. Finally, they discuss Lenalidomide, or Revlimid, and its effectiveness when combined with Rituxan (R-squared).

Interestingly, they also include a section on how they feel current treatments could be used more effectively. Their discussion includes better ways for using the FLIPI index, and PET scans.

In their conclusion, they discuss not only the changes in treatment options that we have seen, but also the ways those changes have challenged our assumptions about Follicular Lymphoma. It's a "moving target," to use their words, but it seems to me that the challenges that researchers face will only improve our future prospects.

Definitely an article worth reading if you want to see where we are with Follicular Lymphoma, based on current research.